Cultural competence in culturally mixed teams

10. Resources

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The term appeal relates to the communication model by Friedemann Schulz von Thun (see “Square of Communication” in this glossary).

Appeal is one of the 4 sides to a message. It influences the receiver into doing, thinking, or feeling certain things. Almost all messages are intended to have some impact on the receiver, rather than merely passing on facts. This can be more or less open or hidden.


Communication is closely connected with social competence and involves personal and interpersonal relationships. It makes use of recognizable symbols such as verbal language, tone of voice etc. as well as non-verbal or body language, such as gestures, eye contact, facial expressions, posture etc.

In this resource, communication is looked at from the point of the “Square of Communication” model.

Read more: “Square of Communication” in this glossary.


In this resource, competence is seen as a necessary prerequisite for meeting complex demands. It refers to the individual’s ability to cope with, create and change situations. Competence requires knowledge, skills and abilities and is shaped by values and attitudes.

Cultural Awareness

Someone's cultural awareness is their understanding of the differences between themselves and people from other cultures or backgrounds, especially differences in attitudes and values. It means understanding, appreciation and consideration of the fact that cultural socialisation has an influence on values, behaviour and beliefs of an individual.

Cultural Competence

Following on from the above descriptions of the terms Competence and Cultural Awareness, Cultural Competence is understood as an individual’s ability to cope with, create and change particular situations which are linked to (assumed or perceived) differences between individuals because of their different backgrounds. As much as the particular kind of knowledge, skills and abilities required might relate to specific cultural aspects, so does it also relate to the individual’s ability and willingness to be open-minded, flexible, adaptable and empathetic and to self-reflect.
Read also: “Self-Reflection” in this glossary

Culturally Mixed Team

Culturally mixed teams consist of members from different cultural backgrounds. For the belonging to a cultural area, nationality is less important than the culture, which is acquired through the socialization in the first culture.

Members of culturally mixed teams need to have transcultural competence in order to work effectively and, in the context of nursing, to ensure their cooperation leads to best patient outcome.

Read also: Transcultural competence in the glossary


The ability of a human to cognitively relate to somebody’s position, which implies to share their feelings and to become clear about their understanding and actions. Empathy requires self-reflection, open-mindedness and the ability to establish a good balance between closeness and distance.

Empathy is a strong element of transcultural competence.

EU Directive on Harmonization of Nurse Education

As early as 1977, a first EU Directive was agreed to harmonize nurse education in order to make it easier for qualified nurses to work in different EU countries. At the time, this was a response to labour market needs which had opened the borders for nurses to move and work in other countries. It had quickly become clear that nurses’ qualifications were not comparable, and in order to keep nurses mobile but at the same time to keep patients safe, the first set of minimum criteria for nurse education was agreed. In 2007, Directive 2005/36/EC on the recognition of professional qualifications came into force, replacing the previous sectoral directives and being edited by Directive 2013/55/EU.

Read more: “Nurse Education” in this glossary.


See:Objective Content in this glossary

Four-Sides Model of Communication

This is used synonymously for: Square of Communication Model. Find more information in this glossary under the term: Square of Communication.

Functioning Communication

Functioning communication means that communicating people do understand each other. In order for communicators to achieve this, they need to be aware of what communication is, how it actually works and what happens in the process of communication. The Square of Communication model presented in the RLO provides one approach to understanding certain aspects of communication and a possible template for analysis of communication processes.

Health Care System

A Health Care System (or Health System) is an organizational structure within a state which has the task to deliver health care services to this state’s population. The design and development of Health Care Systems is based on the population’s health needs as well as on the respective country’s history and political and social structures. Consequently, Health Care Systems are rather diverse and therefore difficult to compare.


In the context of the Square of Communication, the message is the entire package (here called Square) with its verbal and non-verbal parts encoded by the sender and decoded by the receiver. One message contains a variety of information, which can be explicit or implicit. The four sides, or aspects, of the Square refer to “Objective Content”, “Appeal”, “Self-Disclosure” and “Relationship” (find more about these aspects in this glossary). The message with its four aspects serves as a subject for communication analysis. By organizing the multitude of information with the help of the 4 sides of the Square, the full quality of the message becomes clear.


Theory and philosophy of science offer different definitions of what a model is. Schulz von Thun’s communication square as a model abstracts the interpersonal communication situation. The objective of this model is to present the elements influencing any communication process and its possible results as well as to provide a template or structure for analysis of communication processes. Schulz von Thun based this abstraction from Watzlawick’s communication theory. Paul Watzlawick was an Austrian communication researcher, born 25. July 1921 and died 31. March 2007. His seminal book “Pragmatics of Human Communication. A study of Interactional Patterns, Pathologies and Paradoxes” was published in the late 60’s.

Nurse Education

A professional nurse has to have appropriate education. What is to be considered appropriate is dependent on the definition and the scope of nursing in the respective country. In the EU and some countries close to the EU (e.g. Turkey), a so-called Directive harmonizes nurse education, meaning, it provides minimum criteria for nurse education, which have been agreed by the member states. Minimum criteria relate to formal aspects such as entry requirements, length, number of hours, but also places of education (practice places and school) and their ratio. They also relate to content aspects such as competencies to be achieved and knowledge and skills to be acquired.

The EU Directive has to be implemented in each country. This is done in different ways (through national law, through professional council accreditation, etc). Implementation means that the given minimum criteria are the base of the national nurse education programme. It is up to each country, which further criteria, contents or levels they want to include. The interpretation of the minimum criteria as well as the national shaping of nurse education is the area where cultural (and national) aspects can be found.


In the EU and most other countries, nursing is a regulated profession. This means, that the professional title is protected. You are only allowed to call yourself a nurse, if you successfully completed the relevant professional education and have the document proving same. In some countries, the permission to work as a nurse is given by a national professional body (council), with which the nurse needs to register. In other countries, government agencies provide permission to work.

There are many definitions of nursing extant, some coming from researchers in the context of theory development, others from governments or national organisations in the context of regulating the profession within their national health system and in response to their nation’s health care needs or even in the context of workforce management.

According to the International Council of Nurses (ICN), nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings, and it includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Nursing roles also relate to advocacy, promotion of a safe environment, research, participation in shaping health policy and patient and health systems management, as well as education.

Read also: Scope of Nursing in this glossary

Objective Content

The term objective content or fact relates to the communication model by Friedemann Schulz von Thun (see “Square of Communication” in this glossary) and is one of the four sides to a message. Whenever it is facts that count, this aspect should be in the foreground of the message. However, it will always also be accompanied by the other three aspects: appeal, relationship and self-disclosure, thereby potentially leading the interpersonal communication process into a different direction.

Professional Understanding

In this resource, the term professional understanding describes the individual nurse’s belief regarding their professional identity. It encompasses what this nurse thinks and feels makes them being a nurse, how they apply their professional competence and what to them are important values for their nursing practice.

Read also: “Scope of Nursing” in this glossary.


In the context of Schultz von Thun’s communication model, the Square of Communication, the receiver is the person who receives and decodes a message from the sender. The Receiver can choose to double-check the quality of their understanding by giving feedback to the sender about how they decoded the message, what they understood and what it evoked in them


In this resource, the term relationship relates to the communication model by Friedemann Schulz von Thun (see “Square of Communication” in this glossary).

The relationship aspect is one of the four aspects or sides of the message. It reveals the sender’s position towards the receiver of the message and often shows in choice of words, para-verbal and other non-verbal accompanying signals: what I think of you and how we stand with each other.

Schulz von Thun

Friedemann Schulz von Thun (*1944) is a German psychologist. He studied psychology, education and philosophy in Hamburg. He became a professor of educational psychology in Hamburg and founded the “Schultz von Thun Institute for Communication” (1971 to date).

The focus of his work is on “inner democratization”, meaning the equal and partnership-based interpersonal interaction and communication.

Scope of Nursing

The Scope of Nursing is laid down by national or federal law, laying down roles, functions, responsibilities and activities, which a nurse in this country is educated and competent to perform, and has the authority to do so. The Scope of Nursing usually expresses the country’s transfer and implementation of the international definitions of nursing as for example from WHO or ICN into their own Health Care System and structures.

Read also: “Professional Understanding” in this glossary.


In this resource, the term self-disclosure relates to the communication model by Schultz von Thun (see “Square of Communication” in this glossary).

Self-disclosure as one of the four aspects or sides of the message means that the sender always gives something away about himself or herself. This includes intentional self-presentation as well as involuntary self-revelation.


Self-Reflection is an essential part of transcultural competence. Our everyday lifeworld is what we are used to and live in as given, real, natural, self-evident and initially unquestioned. Every judgement, decision and action springs from this personal framework. In teams, several people work together, each bringing in their own lifeworld, particularly so in culturally mixed teams. Each person’s interpretation of what they see and hear from the others is based on their own pool of experiences and knowledge, judged using the frame of their own lifeworld. This has considerable potential to lead to cognitive and/or emotional tensions and stress. Transculturally competent persons will be prepared to deal with such tensions in a constructive way, which is based on self-reflection regarding one’s own “realities” as well as becoming aware of and open for the other person’s perspective.

Self-reflection can be learned. It requires empathy and open-mindedness, and together with transcultural experience and knowledge, it not only leads to transcultural awareness but also to increased self-awareness.


In the context of Schultz von Thun’s communication model, the Square of Communication, the sender is the one who wants to communicate something. He or she encodes their concerns in recognizable symbols: words, sounds, tone of voice, gestures, facial expression, ... The encoded package he sends out is called the message, and it is down to the receiver to decode it. Whether the outgoing and the incoming message corresponds well enough to lead to an understanding depends to a large extend on the interpretation of the codes, and this again may be rather different in different cultures!

Square of Communication

This resource approaches communication based on a communication model developed by Friedemann Schulz von Thun: the Square of Communication. According to this model, every message has four components. The four sides of the message (the square) are: fact or objective content, self-disclosure, relationship and appeal. (The 4 sides are explained at the alphabetically appropriate places in this glossary).

The model is particularly useful to reflect on interpersonal communication, especially if the communication does not lead to understanding or maybe even lead to misunderstanding. (see also: “model” in this glossary)]

Transcultural Competence

Transcultural competence comprises the ability to change perspective and to see the other person from his or her own lifeworld, here and now, in this particular situation. This leads away from culturalization and stereotyping by allocating the person’s behaviour to a particular group, which is defined through particular characteristics.

Transcultural competence does not focus on “culture”, but on interaction between people. Within culturally mixed nursing teams it is the interaction between nurse colleagues.

Transcultural interaction involves the meeting of individual lifeworlds and life experiences.


Hans Böckler Stiftung (Ed.) (2019) Betriebliche Integration von Pflegefachkräften aus dem Ausland [online]. [accessed 30.08.2019]This is a study report on “Employment Integration of professional nurses from foreign countries”. Recently, the German government has followed the strategy of actively recruiting nurses from other countries in response to the shortage of nurses in Germany. This research study, funded by the Hans Böckler Foundation, analyses the processes of integration in the workplace and identifies tensions and stresses developing in these new culturally mixed teams. These tensions are mostly connected to the dimensions of professionalism and expertise, work organisation and cultural aspects.
This publication is available in German.
Hans Böckler Stiftung (Ed.) (2019) Pflegefachkräfte aus dem Ausland: Zahl hat sich versechsfacht – nicht selten Konflikte wegen Unterschieden in Ausbildung und Berufsverständnis [online]. [accessed 30.08.2019]This is a study report on “Nursing professionals from foreign countries: number sextupled – common conflicts stemming from differences in education and professional understanding”. Newly immigrated nurses as well as native employees - who not uncommonly have a migration background themselves - are often dissatisfied with their cooperation. Disputes and misunderstandings which are often due to differences in the professional education and in the way in which tasks are distributed between health care professionals and assistants, are regularly stereotyped and attributed to “cultural differences”. The authors of this study look at structural influences on the problem and suggest how all parties involved could benefit from open-mindedness on the part of employers and native employees towards the migrant nurses and how improved co-determination (making use of their participatory rights) could even lead to organisational development and improvement.
This publication is available in German.
The Federal Government of Germany (continuous updates) Make it in Germany [online]. [accessed 30.08.2019]This is the German government’s official website providing information about living, working and studying in Germany, particularly looking into the field of nursing and nurse education.
This publication is available in English, German and several other languages.
Health Education and Training (HETI) (2019) Cultural awareness [online]. [accessed 30.08.2019]An Australian (New South Wales) approach to defining the term “cultural awareness”.
This publication is available in English.
Koskinen, L., Taylor Kelly, H., Bergknut, E., Lundberg, P., Muir, N., Olt, H., Richardson, E., Sairanen, R. and De Vlieger, L. (2012) European Higher Health Care Education Curriculum: Development of a Cultural Framework. Journal of Transcultural Nursing [online] 23(3): pp. 313-319. [accessed 30.08.2019]The authors present the development of a curriculum framework for the enhancement of cultural competence in European health care education. This framework is the result of a collaborative endeavour by nine nurse educators from five different European countries. The production of the framework is described in accordance with the following tenets: developing cultural competence is a continuing process, cultural competence is based on sensitivity toward others, and cultural competence is a process of progressive inquiry.
This publication is available in English.
European Parliament and Council of the European Union (2013) Directive 2013/55/EU of the European Parliament and of the Council of 20 November 2013 amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System (‘the IMI Regulation’) Official Journal of the European Union [online] 354, 28.12.2013, pp. 132–170 [accessed 30.08.2019]The Directive lays down minimum criteria for nurse education in the EU countries, including objectives and competences.
This publication is available in English, German and several other languages.
Gobbi, M. (2014) Nursing leadership in the European landscape: influence, reality and politics. Journal of Research in Nursing [online] 19(7–8): pp. 636–646. [accessed 30.08.2019]The author presents an overview of the developments in nursing and nurse education in the EU under EU Directives. This publication is available in English.
Hall, C. (2012) TRaNSforM - Training Requirements and Nursing Skills for Mobility in Health Care [online]. [accessed 30.08.2019]The ‘TRaNSforM’ project, funded by the EU Leonardo Programme, involved developing a set of key skills and competences for nurses to enable them to deal effectively with the social and cultural issues of an increasingly diverse workforce and client base. The partners in Belgium, Portugal, Finland, Turkey, Germany, Ireland and England looked at ways to incorporate intercultural learning into existing work-based learning and to map training to the European Qualifications Framework.
Schulz von Thun Institut für Kommunikation The Institute, English Version [online]. [accessed 30.08.2019]Friedemann Schulz von Thun (born 1944) is a German psychologist and expert in interpersonal and intrapersonal communication. Among his various publications is a three-part book series titled "Miteinander Reden" (Talking With Each Other), which has become a standard textbook series in Germany and is widely taught in schools, universities, and vocational training. In nurse education, it is a most commonly used textbook on the subject of communication.
The website is available in German, with this small section of information in English.
Schulz von Thun, F. (2008) Six Tools for Clear Communication. The Hamburg Approach in English Language. Hamburg: Schulz von Thun Institut.This brochure comprises, among others, the Square of Communication model as used in this RLO. It can only be ordered via the Institut.
This publication is available in English.
Schulz von Thun, F. das Kommunikationsquadrat [online]. [accessed 30.08.2019].A short description of the Square of Communication model.
This resource is available in German.

Learning Objective

Learners are sensitive to the underlying cultural dimensions which influence professional understanding and communication in culturally mixed teams in nursing.

Learning Outcomes

By completing this resource you will be able to:

  • show cultural awareness and sensitivity when working in a culturally mixed team.

This resource was developed by:

Content Authors: Inge Bergmann-Tyacke, Annette Nauerth, Simone Neitzel and Katja Makowsky

Language Editors: Mary Brown, Andy Tyacke and Helen Laverty (MBE)

Narrator: Andrew J. Tyacke

Project Mentor: Stathis Konstantinidis

Project Developer: Michael Taylor

Video Production/Development: Adalbert Wojtczak, Benjamin Rohde, Alina Medvedeva-Födisch

Actors: ZaraGizem Tüfekci, SvenjaViola Polesch

Erasmus+ logo

Funding: TransCoCon project - This work was supported by “TransCoCon: Developing Multimedia Learning for Transcultural Collaboration and Competence in Nursing”, a project funded under the ERASMUS+ Programme, (GA No 2017-1-UK01-KA203-036612).

TransCoCon logo Developing Multimedia Learning for Trans-cultural Collaboration and Competence in Nursing.

United Kingdom - University of Nottingham, School of Health Sciences: Stathis Konstantinidis, Mary Brown, Carol Hall, Heather Wharrad, Stacy Johnson, Helen Laverty, Mark Pearson, Michael Taylor.

Germany - Fachhochschule Bielefeld University of Applied Sciences - Faculty of Business and Health - Department of Nursing and Health: Inge Bergmann-Tyacke, Annette Nauerth, Simone Neitzel and Katja Makowsky.

Portugal: ESEP - Center for Health Technology and Services Research Margarida Reis Santos, Candida Koch and Paula Prata.

Belgium: Ho Ghent - University of Applied Sciences and Arts - Faculty of Education, Health and Social Work: Marc Dhaeze, Leen Van Landschoot, Maarten Michels, Sonia Labeau, Ellen Goossens and Deborah Lambotte.

Ireland: St. Angela’s College; A college of NUI Galway - Department of Nursing, Health Science & Disability Studies: Edel McSharry, Denise Healy and Siobhan McGowan.

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